'Low and Slow' Treatment of Insomnia Might Not Be Ideal

A recent study published in Sleep Medicine found that patients may be able to get relief from chronic insomnia with use of placebo pills and half the amount of drugs.

Michael Perlis, PhD, an associate professor in the University of Pennsylvania's department of psychiatry and director of the Penn Behavioral Sleep Medicine Program, and colleagues conducted a study in 74 patients experiencing chronic insomnia. They initially treated the patients with zolpidem 10mg and those who responded to treatment after four weeks were randomized into three dosing groups for 12 weeks: nightly dosing with 5mg or 10mg, “intermittent dosing” of 10mg given 3–5 days a week, or “partial reinforcement” dosing in which half were 10mg capsules and half were placebo capsules.

Results from the study showed that all three strategies demonstrated efficacy in maintaining patient's ability to fall and stay asleep, but those in the intermittent dosing group reported worse sleep, more medical symptoms, and greater symptom severity compared to the other dosing groups.

According to Perlis, these findings also contrast the current standard of “start low and go slow”, as it favors starting patients with a higher dose (10mg nightly) and then switching to a lower dose or intermittent dosing with placebos on non-medication nights. This new approach to dosing sleep medications would allow for a decrease in the amount of medication needed to maintain an effect over time, lower the risk of psychological dependence and side effects, and cut prescription drug cost for patients.

Study findings suggest that with further research, prescribers may be able to indicate the starting dose and schedule of medication and placebo that is need for maintenance therapy in patients with chronic insomnia.

“What is particularly novel about the present study is the use of placebos on non-medication nights and that such a practice appears to extend a level of therapeutic benefit that is not seen with intermittent dosing,” said Perlis. “This effect is thought to occur owing not only to the enhancement of patient expectancy but to the conditioning of medication effects, i.e., the medication induced effects may be elicited, with conditioning, by the medication capsule itself and that this can be sustained over time with occasional use of full dose medication (partial reinforcement).”